From the Guidelines
The workup for suspected carpal tunnel syndrome (CTS) should begin with a thorough history and physical examination, focusing on symptoms like numbness, tingling, or pain in the thumb, index, middle, and radial half of the ring finger, especially at night or with repetitive activities. Physical examination should include Tinel's sign (tapping over the median nerve at the wrist), Phalen's test (wrist flexion for 60 seconds), and carpal compression test. Electrodiagnostic studies (nerve conduction studies and electromyography) are recommended to confirm the diagnosis and assess severity, as suspected carpal tunnel syndrome is diagnosed by clinical evaluation combined with electrophysiologic studies 1. Initial management includes conservative measures such as:
- Wrist splinting in a neutral position at night and during aggravating activities
- Activity modification
- Ergonomic workplace adjustments For pain relief, NSAIDs like ibuprofen (400-600mg three times daily) can be used. If symptoms persist, corticosteroid injections (methylprednisolone 20-40mg with lidocaine) into the carpal tunnel may provide temporary relief. For moderate to severe cases or those not responding to conservative treatment after 6-12 weeks, surgical decompression (carpal tunnel release) should be considered, with either open or endoscopic techniques being about as effective as each other in relieving symptoms and improving functional status 1. Surgery involves transecting the transverse carpal ligament to relieve pressure on the median nerve and can be performed using open or endoscopic techniques, with most patients experiencing significant improvement in symptoms. Early diagnosis and treatment are important to prevent permanent nerve damage and muscle atrophy. Further imaging is usually not needed, but in selected circumstances, either wrist US or MRI without contrast may be appropriate 1.
From the Research
Diagnosis and Initial Evaluation
- Carpal tunnel syndrome (CTS) diagnosis is typically made clinically, with electrodiagnostic studies performed only when clinical signs are equivocal 2
- Classic symptoms of CTS include pain and paresthesias in the distribution of the median nerve, while Tinel's sign and a positive Phalen's maneuver are classic clinical signs 3
- Hypalgesia and weak thumb abduction are more predictive of abnormal nerve conduction studies 3
Conservative Management
- Conservative treatment options for CTS include splinting the wrist in a neutral position, ultrasound therapy, and orally administered corticosteroids 3
- Local corticosteroid injections may improve symptoms for a longer period than oral corticosteroids 4, 3
- Nonsteroidal anti-inflammatory drugs, pyridoxine, and diuretics are no more effective than placebo in relieving CTS symptoms 4, 3, 5
- Activity modification, such as reducing activities that exacerbate symptoms, is also recommended 4
Role of Nerve Conduction Studies and EMG
- Nerve conduction studies should be performed to assist in diagnosis and may need to be repeated at intervals in those managed conservatively 6
- Electrodiagnostic studies (EDX) are recommended before any invasive procedure for CTS, including injection or surgery 6
- Needle EMG studies may be needed in those with severe disease or when an alternate or concomitant diagnosis is suspected 6